What is the significance of having a Low-Density Lipoprotein (LDL) level of 20 and a Very-Low-Density Lipoprotein (VLDL) level of 38?

Significance of LDL 20 mg/dL and VLDL 38 mg/dL

Your LDL of 20 mg/dL is extremely low and represents a very favorable cardiovascular risk profile with no safety concerns, while your VLDL of 38 mg/dL is within normal range and does not require intervention. 1, 2

Understanding Your LDL Level of 20 mg/dL

Cardiovascular Protection

• An LDL level of 20 mg/dL places you in the "very low" category (<50 mg/dL) and is associated with maximal cardiovascular protection. 1
• Long-term achievement of LDL levels below 20 mg/dL has been shown to reduce cardiovascular events (heart attack, stroke, coronary revascularization) with no significant safety concerns in studies following patients up to 8.6 years. 3
• The relationship between LDL and cardiovascular disease is log-linear, meaning that lower levels continue to provide benefit without a threshold below which protection stops. 1

Safety at Very Low Levels

• No statistically significant adverse effects have been identified with LDL levels below 20 mg/dL, including no increased risk of serious adverse events, cancer, hemorrhagic stroke, diabetes, neurocognitive problems, or muscle-related events. 1, 3
• Individuals with genetic conditions causing lifelong very low LDL cholesterol demonstrate that these levels are safe long-term. 1
• Recent high-quality evidence from the FOURIER-OLE study (2023) followed patients for up to 8.6 years with LDL levels <20 mg/dL and found continued cardiovascular benefit without safety concerns. 3

Context for Your LDL Level

• Standard LDL targets are <100 mg/dL for high-risk patients, with optional goals of <70 mg/dL for very high-risk patients. 4
• Your level of 20 mg/dL is far below even the most aggressive treatment targets, suggesting either genetic factors, intensive lipid-lowering therapy, or both. 1, 4

Understanding Your VLDL Level of 38 mg/dL

Normal Range Assessment

• Your VLDL of 38 mg/dL is within the normal range and does not require treatment. 2
• VLDL carries triglycerides from the liver to peripheral tissues and is atherogenic (promotes plaque formation), but your level is not elevated. 2
• VLDL levels correlate with triglyceride levels, as VLDL is 80-95% triglyceride by composition. 2

Cardiovascular Risk Implications

• Elevated VLDL cholesterol (≥30 mg/dL) has been associated with increased coronary heart disease risk in large cohort studies, but your level of 38 mg/dL, while technically above 30 mg/dL, is still considered within acceptable limits. 5
• The combination of LDL and VLDL cholesterol is called non-HDL cholesterol, which is a secondary target when triglycerides are ≥200 mg/dL (target <130 mg/dL). 2
• Your non-HDL cholesterol would be approximately 58 mg/dL (20 + 38), which is exceptionally low and highly protective. 2

When VLDL Becomes Concerning

• VLDL becomes a treatment target when triglycerides are ≥500 mg/dL (severe hypertriglyceridemia) to prevent acute pancreatitis. 2
• For moderate hypertriglyceridemia with residual cardiovascular risk, additional therapy may be considered, but this does not apply to your current levels. 2

Clinical Implications

If You Are on Lipid-Lowering Therapy

• Your LDL of 20 mg/dL likely reflects intensive statin therapy, possibly combined with ezetimibe or PCSK9 inhibitors. 1, 3
• Continue your current therapy as prescribed—these levels provide maximal cardiovascular protection without safety concerns. 3
• Your physician should monitor lipid levels periodically (typically every 4-6 months once stable) to ensure consistency. 2

If You Are Not on Lipid-Lowering Therapy

• An LDL of 20 mg/dL without medication suggests a genetic condition causing hypocholesterolemia (such as PCSK9 loss-of-function mutations or familial hypobetalipoproteinemia). 1
• These genetic conditions are associated with lifelong cardiovascular protection and no adverse health effects. 1
• No intervention is needed, but genetic counseling may be valuable if you have family members who could benefit from testing. 1

Overall Risk Assessment

• Your lipid profile indicates exceptionally low cardiovascular risk from a cholesterol standpoint. 1
• The combination of very low LDL and normal VLDL represents an optimal lipid profile for cardiovascular health. 6, 2
• Focus should remain on other cardiovascular risk factors (blood pressure, diabetes control, smoking cessation, physical activity) as these become relatively more important when cholesterol is optimally controlled. 1